This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Houkin, K. Articles by Kuroda, S. Search for Related Content PubMed PubMed Citation Articles by Houkin, K. Articles by Kuroda, S.

(Stroke. 1996;27:1342-1346.)
© 1996 American Heart Association, Inc.

Articles

Surgical Therapy for Adult Moyamoya Disease

Can Surgical Revascularization Prevent the Recurrence of Intracerebral Hemorrhage?

Kiyohiro Houkin, MD; Hiroyasu Kamiyama, MD; Hiroshi Abe, MD; Akihiro Takahashi, MD Satoshi Kuroda, MD

the Department of Neurosurgery, Hokkaido University School of Medicine, Sapporo, Japan.

	Abstract

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Background and Purpose It is well recognized that revascularization surgery using direct and/or indirect bypass provides effective surgical management for pediatric moyamoya disease. However, surgical treatment of the adult hemorrhagic type remains controversial. In this study, the effect of surgery for adult moyamoya disease was investigated.

Methods We analyzed 35 patients with adult moyamoya disease (patient age, over 20 years), 24 patients with initial onset of intracerebral hemorrhage, and 11 patients with initial onset of cerebral ischemia who underwent both direct bypass surgery of the superficial temporal artery to the middle cerebral artery anastomosis and indirect revascularization of encephalo-duro-arterio-myo-synangiosis.

Results Of 24 patients with hemorrhagic-type disease, 3 showed rebleeding; of 11 patients with the ischemic type, 2 showed intracerebral hemorrhage after surgery. Overall, 5 of 35 patients (14.3%) had hemorrhage after revascularization surgery (mean follow-up period, 6.4 years). Postoperative angiography revealed that direct anastomosis is effective whereas indirect revascularization is not always effective for adult moyamoya disease. Moyamoya vessels, which are supposed to be responsible for hemorrhage, decreased in 25% of patients.

Conclusions Revascularization surgery cannot always prevent rebleeding. However, a decrease in moyamoya vessels was induced by surgery, which may reduce the risk of hemorrhage more effectively than conservative treatment. In cases of adult moyamoya disease, direct bypass is particularly important, since the indirect revascularization is not as useful in adult cases as in pediatric cases.

Key Words: cerebral hemorrhage • moyamoya disease • extracranial-intracranial arterial bypass

	Introduction

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Moyamoya disease is characterized by the progressive steno-occlusive change in the anterior circulation of the circle of Willis and the abnormal development of moyamoya vessels (which means "puff of smoke" vessels in Japanese) in the basal ganglia. The age distribution of patients with this disease forms two characteristic peaks in children and adults.^{1 2} In the pediatric group, the initial symptom is mainly cerebral ischemia, whereas in the adult group ICH is the most common initial presentation.^{1 2} Regarding the ischemic type of moyamoya disease, which is seen in most cases of pediatric moyamoya disease and some cases of adult moyamoya disease, revascularization surgery by direct and indirect bypass is effective in preventing cerebral ischemia, since revascularization surgery improves cerebral ischemia and reduces the hemodynamic stress on the collateral circulation, including the moyamoya vessels.^{3 4 5 6 7} However, it remains controversial whether revascularization surgery is useful in preventing cerebral hemorrhage in the hemorrhagic type of the disease commonly seen in the adult group.^{8 9 10}

In this study, we analyzed 35 consecutive patients with adult moyamoya disease who underwent combined surgical therapy by both direct revascularization and indirect revascularization. In particular, the following two points were analyzed: (1) Can this combined surgical revascularization surgery prevent rebleeding in the hemorrhagic type of adult moyamoya disease? (2) Does indirect or direct bypass provide more effective revascularization for the brain in adult moyamoya cases?

	Subjects and Methods

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Patients
In this study, moyamoya disease was defined as adult type if a patient had the initial attack of moyamoya disease after 20 years of age. We treated 35 cases of adult moyamoya disease at Hokkaido University Hospital and its affiliate hospitals between 1985 and 1994. Patient ages ranged from 24 to 67 years (mean, 48 years). Twenty-six patients were women, and 9 were men. Of these 35 cases, 24 patients showed initial symptoms of ICH, and 11 showed ischemic attack. All patients underwent surgical therapy. The details of our surgical technique have been reported elsewhere.¹¹ Briefly, in all cases, direct revascularization was performed by anastomosis of the STA to the MCA and indirect revascularization by EDAMS. EDAMS is a procedure to place vascularized tissues such as the STA, middle meningeal artery, and temporal muscle on the brain surface. This combined surgical revascularization was performed on 51 sides. For comparison with pediatric moyamoya disease, 12 patients with pediatric moyamoya disease (22 sides), all of the ischemic type, who underwent the same surgical management in the same period were also analyzed. All the patients were examined with conventional angiography both before and after sugery. All adult patients were followed up for a mean duration of 6.4 years.

Angiographic Analysis
As previously shown, MR angiography is becoming a reliable diagnostic modality for moyamoya disease.¹² However, in this study, all patients underwent complete conventional angiography before and after surgery because precise analysis of angiographic findings was necessary, especially to demonstrate the changes in moyamoya vessels. Angiography was performed 6 months after surgery in most cases. Postoperative evaluations of the effectiveness of direct and indirect bypass were made as follows: (1) Direct anastomosis (STA-MCA) was evaluated as "good" when the width of the anastomosed STA increased and the site of anastomosis was clearly identified. In other words, direct bypass was evaluated as "poor" if these criteria were not met. (2) Indirect bypass (EDAMS) was evaluated as good when the middle meningeal artery, STA, and deep temporal artery (muscle branch) made fine new channels to the cortical artery. Otherwise, this revascularization was evaluated as poor. The changes in moyamoya vessels were also evaluated by simple comparison between the preoperative and postoperative angiography.

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
Rebleeding After Surgery
As shown in Table 1, of 24 cases with initial clinical presentation of ICH, 3 (12.5%) showed rebleeding. Of 11 cases of cerebral ischemia, 2 (18%) showed a second attack of ICH. In these 11 ischemic cases, recurrence of ischemic attack was not seen. However, of 24 cases in the hemorrhagic group, 2 (8%) showed signs of cerebral ischemia during the follow-up period. Totally, in 14.3% (5 of 35 cases) of all adult-type moyamoya disease, rebleeding occurred even after bypass surgery. Overall, some stroke (bleeding or ischemia) occurred in 20% (7 of 35 cases) in our study. In 3 cases showing rebleeding after initial ICH, 1 showed 2 episodes of rebleeding (3 episodes of bleeding in total). The second hemorrhage was seen in a different location of the brain, although it is well known that hemorrhage of the paraventricle area and intraventricle hemorrhage are the most common types (Fig 1).

View this table: [in this window] [in a new window]   Table 1. Type of Reattack

View larger version (62K): [in this window] [in a new window]   Figure 1. Rebleeding after surgery in a 52-year-old woman. The first hemorrhage (1st) occurred on February 25, 1992. Bilateral STA-MCA anastomosis and EDAMS were performed. However, a second (2nd) and third (3rd) hemorrhage occurred.

The mean interval between the first and second hemorrhage was 4.8 years after surgical therapy. Fortunately, none of the patients died even after recurrent hemorrhage, although 1 patient remains in a vegetative state because of the second hemorrhage.

Postoperative Angiographic Change
In the 35 adult cases, 47 sides were completely examined by conventional angiography (including arterial digital subtraction angiography) before and after surgery. For comparison with pediatric moyamoya disease, preoperative and postoperative angiography of 22 sides in pediatric moyamoya patients were also analyzed.

Comparison Between Direct Revascularization by STA-MCA Anastomosis and Indirect Revascularization by EDAMS
The effects in the adult and pediatric groups of each revascularization method are summarized in Table 2. In adult patients, direct revascularization of STA-MCA was highly effective (90%), whereas indirect revascularization was not very effective. Fig 2 shows representative cases.

View this table: [in this window] [in a new window]   Table 2. Effect of Revascularization Surgery

View larger version (85K): [in this window] [in a new window]   Figure 2. Postoperative angiography in adult patients shows a demonstrative case of good STA-MCA anastomosis and EDAMS (left) and a case in which EDAMS was poor but STA-MCA anastomosis was good (right).

In pediatric moyamoya disease, STA-MCA anastomosis was effective in 68% of cases, which was significantly lower than that in adult moyamoya disease. However, indirect revascularization by EDAMS was effective in 100% without any exception. Statistical analysis revealed that direct bypass is more effective in adult cases than pediatric cases (P<.05, ² test) and that indirect revascularization is more effective in pediatric cases than adult cases (P<.001, ² test). Fig 3 shows representative cases of adult and pediatric moyamoya disease, revealing good STA-MCA anastomosis and poor EDAMS in adult cases and good EDAMS in pediatric cases.

View larger version (111K): [in this window] [in a new window]   Figure 3. Top, Lateral view of selective external carotid artery angiography in a postoperative pediatric case. Very good revascularization from STA-MCA anastomosis and EDAMS was seen. Bottom, Lateral view of selective external carotid artery angiography in a postoperative adult case. STA-MCA anastomosis was good; however, EDAMS was poor.

Change in Moyamoya Vessels After Surgery
In adult cases, moyamoya vessels diminished in only 25%, whereas there was no significant change in moyamoya vessels in 75%. However, in pediatric cases, significant change in moyamoya vessels was seen in 100%. There is a significant difference in the diminishment of moyamoya vessels between pediatric and adult cases (P<.001, ² test). Fig 4 shows representative cases, revealing no significant change in moyamoya vessels in an adult patient and reduction in moyamoya vessel after surgery in a pediatric patient.

View larger version (346K): [in this window] [in a new window]   Figure 4. Left, Preoperative and postoperative angiograms of a 61-year-old man (hemorrhagic onset) show that moyamoya vessels were not diminished. Right, Preoperative and postoperative angiograms of a 3-year-old girl (ischemic onset) show a drastic reduction of moyamoya vessels.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
As is well known, two different types of initial clinical presentation are observed in moyamoya disease: cerebral ischemic attack, seen mainly in pediatric patients, and ICH (intraventricular hemorrhage in some cases), seen mainly in adults.^{1 2} The incidence of hemorrhage is reported to exceed 60% in adults, while it is only 10% in children.¹³ In general, however, the same surgical strategy has been used to treat these apparently different pathological conditions. The basic and established treatment of moyamoya disease is to induce a revascularization channel from the extracerebral arterial system to the brain surface, although numerous variations of surgical management, such as encephalo-myo-synangiosis, encephalo-galeo-synagiosis, encephalo-duro-arterio-synangiosis, and omentum transplantation, have been reported.^{3 4 5 6 7 14} Our basic strategy for this disease principally follows this general concept. Namely, we combine direct and indirect revascularization methods as effectively as possible. Temporal muscle, dura mater (middle meningeal artery), and STA, which are potentially powerful blood donors to the ischemic moyamoya brain, are maximally utilized in our surgery. Moreover, we perform direct STA-MCA anastomosis to the frontal cortex, which is hardly covered by the temporal muscle.¹¹ As far as cerebral ischemia is concerned, this revascularization method effectively improves the cerebral blood circulation and the circulation reserve as shown by positron emission tomography and single-photon emission tomography.^{15 16} Clinically, most patients are free from cerebral ischemic attack and other symptoms such as retractable epilepsy after successful revascularization surgery.^{7 9 10} However, medical treatment for this disease has failed to prevent the progression of symptoms due to ischemia.¹⁷

There is controversy regarding the effect of this revascularization surgery in preventing the recurrent ICH seen in adult moyamoya disease.^{8 9 10 18 19} In discussion of this controversial issue, the mechanism of intracerebral bleeding seen in moyamoya disease must be considered. Presently, the associated small aneurysm in the circle of Willis (mainly the posterior circulation) and microaneurysm of the abnormally dilated moyamoya vessels are considered the origins of hemorrhage.^{20 21 22 23} When aneurysms are detected in the circle of Willis or in moyamoya vessels on angiography, these aneurysms should be treated. Indeed, Hamada et al²² reported two cases of moyamoya disease with repeated intraventricular hemorrhage due to microaneurysm rupture and the clipping or trapping of parent arteries. Recently, endovascular treatment for the saccular aneurysm in moyamoya disease using electrically detachable coil was also reported.²³ However, in general, it is unusual for these small microaneurysms to be detected on angiography, especially in cases involving the hemorrhagic type of moyamoya disease, as in hypertensive intracerebral hematoma. However, these microaneurysms are supposed to be induced by hemodynamic stress to the moyamoya vessels, which are abnormally dilated to compensate for ischemia due to steno-occlusive change in the main trunk of the anterior circulation of the circle of Willis.^{13 22 24} Therefore, practical management for the hemorrhagic-type moyamoya disease, in which apparent microaneurysms responsible for hemorrhage are not demonstrated on angiography, is to decrease this hemodynamic stress and consequently induce a decrease in the moyamoya vessels. The rationale for revascularization surgery to reduce the risk of hemorrhage in moyamoya disease is deduced from the concept that the appropriate revascularization can decrease hemodynamic stress on the collateral circulation.^{9 10}

There has not been any randomized study to test the practical effect of this revascularization surgery on reducing the risk of hemorrhage in moyamoya disease. The clinical course of conservative therapy for the adult hemorrhagic type of moyamoya disease has not been discussed thoroughly.^{8 25} A nationwide survey in Japan by Kudo and Fukuda² in 1979 showed that 10 of 58 patients (17%) whose age at onset was more than 16 years had recurrent hemorrhage. Another survey by Nishimoto et al²⁶ also revealed that 33% of 175 patients with hemorrhagic attacks due to moyamoya disease sought medical attention because of repeated bleeding. The incidence of rebleeding in adult moyamoya disease reported in that study seems to be higher than the incidence in our study (14.5%). Wanifuchi et al²⁷ reported 59 cases of adult moyamoya disease, which included 38 patients treated conservatively and 21 treated with surgical therapy. In their article, they concluded that hemorrhage recurrence in the surgical group was much less common than in the conservative-treatment group. These results suggest that surgical treatment is superior to conservative therapy in reducing the risk of rebleeding. Moreover, our results clearly revealed that decrease of moyamoya vessels was induced by revascularization surgery even in adult cases, although the effect is less than that in pediatric cases. However, these data are not well randomized, and further long-term follow-up study and discrete analysis are required to establish the superiority of surgery. In addition, long-term follow-up of pediatric moyamoya patients who were surgically treated is tremendously important to evaluate the long-term results of revascularization surgery.^{9 10}

Our results also disclosed a very important aspect of surgical therapy for adult moyamoya disease: direct revascularization by STA-MCA is much more effective than indirect revascularization in adult moyamoya disease.²⁸ However, in pediatric moyamoya disease, indirect revascularization is 100% effective, whereas direct revascularization has failed in some cases because of the extraordinarily small donor and recipient vessels. The reason why indirect revascularization was not as effective in adult cases is not clear. However, the severity of cerebral ischemia in adult patients, which is considered the main driving force that induces the neovascularization from indirect revascularization, is mild. Moreover, as we have shown, basic fibroblast growth factor in the cerebrospinal fluid, a cytokine which we consider important in inducing neovascularization in moyamoya disease, is not as elevated in adult compared with pediatric patients.²⁹

In conclusion, the superiority of surgical treatment for the adult hemorrhagic type of moyamoya disease must be tested by long-term follow-up study. However, as we have shown, effective revascularization surgery with both direct and indirect revascularization can decrease the moyamoya vessels in adult patients. Direct revascularization by STA-MCA anastomosis is an indispensable method for effective revascularization, especially in adult patients.

	Selected Abbreviations and Acronyms

 

EDAMS = encephalo-duro-arterio-myo-synangiosis ICH = intracerebral hemorrhage MCA = middle cerebral artery STA = superficial temporal artery

	Acknowledgments

 
This study was supported in part by grants from the research committee on spontaneous occlusion of the circle of Willis of the Ministry of Health and Welfare (Japan). We wish to thank Yukari Nagasaki and Masayuki Kimura for preparation of this manuscript.

	Footnotes

 
Reprint requests to Kiyohiro Houkin, MD, Department of Neurosurgery, Hokkaido University School of Medicine, Kita-Ku, N-15, W-7, Sapporo, 060, Japan. E-mail khokin@med.hokudai.ac.jp.

Received March 4, 1996; revision received April 9, 1996; accepted April 9, 1996.

	References

Top Abstract Introduction Subjects and Methods Results Discussion References

 
1. Suzuki J, Kodama N. Moyamoya disease: a review. Stroke. 1983;14:104-109.[Abstract/Free Full Text]

2. Kudo T, Fukuda S. Spontaneous occlusion of the circle of Willis: a disease entity, its pathology and clinical features [in Japanese]. Adv Neurol Sci. 1976;20:750-757.

3. Karasawa J, Kikuchi H, Furuse S, Sakaki T, Yoshida Y, Ohnishi H, Taki W. A surgical treatment of `Moyamoya' disease: `encephalo-myo-synangiosis.' Neurol Med Chir (Tokyo). 1977;17:29-37.[Medline] [Order article via Infotrieve]

4. Karasawa J, Kikuchi H, Furuse S, Kawamura J, Sakaki T. Treatment of moyamoya disease with STA-MCA anastomosis. J Neurosurg. 1978;49:679-688.[Medline] [Order article via Infotrieve]

5. Karasawa J, Kikuchi H, Kawamura J, Sakaki T. Intracranial transplantation of the omentum for cerebrovascular moyamoya disease: a two-year follow-up study. Surg Neurol. 1980;14:444-449.[Medline] [Order article via Infotrieve]

6. Kikuchi H, Karasawa J. Extracranial-intracranial arterial anastomosis in ten patients with moyamoya syndrome. In: Schmiedek P, ed. Microsurgery for Stroke. Heidelberg, Germany: Springer-Verlag; 1976:260-263.

7. Kinugasa K, Mandai S, Kamata I, Sugui K, Ohmoto T. Surgical treatment of moyamoya disease: operative technique for encephalo-duro-arterio-myo-synagiosis, its follow-up, clinical results and angiograms. Neurosurgery. 1993;32:527-531.[Medline] [Order article via Infotrieve]

8. Matsushima Y, Suzuki R, Yamaguchi T, Tabata H, Inaba Y. Effect of indirect EC/IC bypass operation on adult moyamoya patients [in Japanese]. No Shinkei Geka. 1986;14:1559-1566.[Medline] [Order article via Infotrieve]

9. Nakagawa Y, Abe H, Kamiyama H, Sawamura Y, Gotoh S, Kashiwaba T. Revascularization surgery for 50 patients with moyamoya disease. In: Suzuki J, ed. Advances in Surgery for Cerebral Stroke. Tokyo, Japan: Springer-Verlag; 1988:141-149.

10. Nakagawa Y, Abe H, Sawamura Y, Kamiyama H, Gotoh S, Kashiwaba T. Revascularization surgery for moyamoya disease. Neurol Res. 1988;10:32-39.[Medline] [Order article via Infotrieve]

11. Takahashi A, Kamiyama H, Houkin K, Abe H. Surgical treatment of pediatric moyamoya disease: comparison between the reconstructive surgery centered on the frontal region and that centered on the parietal region. Neurol Med Chir (Tokyo). 1995;35:231-237.[Medline] [Order article via Infotrieve]

12. Houkin K, Aoki T, Takahashi A, Abe H. Diagnosis of moyamoya disease with magnetic resonance angiography. Stroke. 1994;25:2159-2164.[Abstract]

13. Nishimoto A. Moyamoya disease [in Japanese]. Neurol Med Chir (Tokyo). 1979;19:221-228.[Medline] [Order article via Infotrieve]

14. Matsushima T, Inoue T, Suzuki SO, Fujii K, Fukui M, Hasuo K. Surgical treatment of moyamoya disease in pediatric patients: comparison between the results of indirect and direct revascularization procedures. Neurosurgery. 1992;31:401-405.[Medline] [Order article via Infotrieve]

15. Ikezaki K, Matsushima T, Kuwabara Y, Suzuki SO, Nomura T, Fukui M. Cerebral circulation and oxygen metabolism in pediatric moyamoya disease: a perioperative positron emission tomography study. J Neurosurg. 1994;81:843-850.[Medline] [Order article via Infotrieve]

16. Isobe M, Kuroda S, Kamiyama H, Abe H, Mitsumori K. Cerebral blood flow reactivity to hyperventilation in children with spontaneous occlusion of the circle of Willis (Moyamoya disease) [in Japanese]. No Shinkei Geka. 1992;20:399-407.[Medline] [Order article via Infotrieve]

17. Kurokawa T, Tomita S, Ueda K, Narazaki O, Hanai T, Hasuo K, Matsushima T, Kitamura K. Prognosis of occlusive disease of the circle of Willis (moyamoya disease) in children. Pediatr Neurol. 1985;1:274-277.[Medline] [Order article via Infotrieve]

18. Aoki N. Cerebrovascular bypass surgery for the treatment of Moyamoya disease: unsatisfactory outcome in the patients presenting intracranial hemorrhage. Surg Neurol. 1993;40:372-377.[Medline] [Order article via Infotrieve]

19. Ueki K, Meyer FB, Mellinger JF. Moyamoya disease: the disorder and surgical treatment. Mayo Clin Proc. 1994;69:749-757.[Medline] [Order article via Infotrieve]

20. Adams HP, Kassel NF, Wisoff HS, Drake CG. Intracranial saccular aneurysm and moyamoya disease. Stroke. 1979;10:174-179.[Abstract/Free Full Text]

21. Furuse S, Matsumoto S, Tanaka Y, Ando S, Sawa H, Ishikawa S. Moyamoya disease associated with a false aneurysm: case report and review of the literature [in Japanese]. No Shinkei Geka. 1982;10:1005-1012.[Medline] [Order article via Infotrieve]

22. Hamada J, Hashimoto N, Tsukahara T. Moyamoya disease with repeated intraventricular hemorrhage due to aneurysm rupture. J Neurosurg. 1994;80:328-331.[Medline] [Order article via Infotrieve]

23. Massoud TF, Guglielmi G, Vinuela F, Duckwiler GR. Saccular aneurysms in moyamoya disease: endovascular treatment using electrically detachable coils. Surg Neurol. 1994;41:462-467.[Medline] [Order article via Infotrieve]

24. Kodama N, Suzuki J. Moyamoya disease associated with aneurysm. J Neurosurg. 1978;48:565-569.[Medline] [Order article via Infotrieve]

25. Miyamoto S, Kikuchi H, Karasawa J, Nagata I, Yanazoe N, Akiyama Y. Pitfalls in the surgical treatment of moyamoya disease: operative techniques for refractory cases. J Neurosurg. 1988;68:537-543.[Medline] [Order article via Infotrieve]

26. Nishimoto A, Ueda K, Honma Y. Follow-up study on outcome of the occlusion of the circle of Willis. In: Gotoh S, ed. 1982 Proceedings of the Research Committee on Spontaneous Occlusion of the Circle of Willis [in Japanese]. Tokyo, Japan: Ministry of Health and Welfare; 1983:66-74.

27. Wanifuchi H, Takeshita M, Izawa M, Aoki N, Kagawa M. Management of adult moyamoya disease. Neurol Med Chir (Tokyo). 1993;33:300-305.[Medline] [Order article via Infotrieve]

28. Asfora WT, West M, McClarty B. Angiography of encephalomyosynangiosis and superficial temporal artery to middle cerebral artery anastomosis in moyamoya disease. AJNR Am J Neuroradiol. 1993;14:29-30.[Abstract]

29. Takahashi A, Sawamura Y, Houkin K, Kamiyama H, Abe H. The cerebrospinal fluid in patients with moyamoya disease (spontaneous occlusion of the circle of Willis) contains high level of basic fibroblast growth factor. Neurosci Lett. 1993;160:214-216.[Medline] [Order article via Infotrieve]

This article has been cited by other articles:

				R. M. Scott and E. R. Smith Moyamoya Disease and Moyamoya Syndrome N. Engl. J. Med., March 19, 2009; 360(12): 1226 - 1237. [Full Text] [PDF]

				S. Kuroda, N. Hashimoto, T. Yoshimoto, Y. Iwasaki, and for the Research Committee on Moyamoya Disease in Radiological Findings, Clinical Course, and Outcome in Asymptomatic Moyamoya Disease: Results of Multicenter Survey in Japan Stroke, May 1, 2007; 38(5): 1430 - 1435. [Abstract] [Full Text] [PDF]

				Y. So, H.-Y. Lee, S.-K. Kim, J. S. Lee, K.-C. Wang, B.-K. Cho, E. Kang, and D. S. Lee Prediction of the Clinical Outcome of Pediatric Moyamoya Disease With Postoperative Basal/Acetazolamide Stress Brain Perfusion SPECT After Revascularization Surgery Stroke, July 1, 2005; 36(7): 1485 - 1489. [Abstract] [Full Text] [PDF]

				M. Morioka, J.-I. Hamada, T. Kawano, T. Todaka, S. Yano, Y. Kai, and Y. Ushio Angiographic Dilatation and Branch Extension of the Anterior Choroidal and Posterior Communicating Arteries Are Predictors of Hemorrhage in Adult Moyamoya Patients Stroke, January 1, 2003; 34(1): 90 - 95. [Abstract] [Full Text] [PDF]

				K. Ikezaki Rational Approach to Treatment of Moyamoya Disease in Childhood J Child Neurol, May 1, 2000; 15(5): 350 - 356. [Abstract] [PDF]

				Y. Yoshida, T. Yoshimoto, R. Shirane, and Y. Sakurai Clinical Course, Surgical Management, and Long-Term Outcome of Moyamoya Patients With Rebleeding After an Episode of Intracerebral Hemorrhage : An Extensive Follow-Up Study Stroke, November 1, 1999; 30(11): 2272 - 2276. [Abstract] [Full Text] [PDF]

				D. Chiu, P. Shedden, P. Bratina, and J. C. Grotta Clinical Features of Moyamoya Disease in the United States Stroke, July 1, 1998; 29(7): 1347 - 1351. [Abstract] [Full Text] [PDF]

				Y. Okada, T. Shima, M. Nishida, K. Yamane, T. Yamada, and C. Yamanaka Effectiveness of Superficial Temporal Artery–Middle Cerebral Artery Anastomosis in Adult Moyamoya Disease : Cerebral Hemodynamics and Clinical Course in Ischemic and Hemorrhagic Varieties Stroke, March 1, 1998; 29(3): 625 - 630. [Abstract] [Full Text] [PDF]

				T. Ishikawa, K. Houkin, H. Kamiyama, and H. Abe Effects of Surgical Revascularization on Outcome of Patients With Pediatric Moyamoya Disease Stroke, June 1, 1997; 28(6): 1170 - 1173. [Abstract] [Full Text]

				T. Yoshimoto, K. Houkin, A. Takahashi, and H. Abe Angiogenic Factors in Moyamoya Disease Stroke, December 1, 1996; 27(12): 2160 - 2165. [Abstract] [Full Text]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Houkin, K. Articles by Kuroda, S. Search for Related Content PubMed PubMed Citation Articles by Houkin, K. Articles by Kuroda, S.